"Doughnut" granulomas from erythema nodosum in acute Q fever.

" Doughnut " Granulomas in Acute Q Fever Q fever is a zoonotic infection caused by Coxiella burnetii. The disease has two forms, acute and chronic. The acute form usually manifests as pneumonia, hepatitis, a combination of the two, or a flu‑like syndrome. Skin manifestations during the acute disease are uncommon. Diagnosis of Q fever is based on positive serology tests. Liver and bone biopsies may show characteristic " doughnut " granulomata [1‑4]. We describe a patient with an acute C. burnetii infection, presented as fever, a large angry‑looking skin lesion and a characteristic " doughnut " granuloma on skin biopsy. A 70 year old woman was admitted to our ward with a fever that had not abated for 1 week. There were no other symptoms of disease, no history of recent travel or contact with sick individuals, and there was no recall of animal contact. Since her past medical history included colon cancer treated by chemotherapy, we were concerned that her current symptoms might be associated with recurrence and admitted her for observation. On admission, fever was 37.8°C. Physical examination was completely normal and there were no pathological skin manifestations. Blood test results were unremarkable except for C‑reactive protein levels, which rose from 38 to > 100 mg/dl during hospitalization (normal range 0–5 mg/dl). Investigation of fever origin included blood and urine cultures and serol‑ ogy tests for common viruses and other bacteria: all the results were negative. A computed tomography scan of the chest, abdomen and pelvis failed to reveal a source for the fever or the presence of any other pathology, and the findings of a complete array of markers for an autoimmune dis ease were negative. One week after her admission, she developed a widespread skin rash on her right lower leg. The skin lesion was biopsied and a 1 week course of cloxacillin and ampicillin for possible cellulitis was started, but there was no improvement in her general condition, fever pattern or skin rash. Three weeks after her admission, the results of serology testing were positive for an acute C. brunnetii infection. The first blood test that was performed on admission had shown negative titers for Q fever phase I and a 1:32 titers for Q fever phase II. The second test, taken 2 weeks later, showed a seroconversion, with a titer of > 1024 for Q fever phase II. The results indicated an acute …